Hyperosmolar Hyperglycemic State

Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis. With the dramatic increase in the prevalence of type 2 diabetes and the aging population, this condition may be encountered more frequently by family physicians in the future. Although the precipitating causes are numerous, underlying infections are the most common. Other causes include certain medications, non-compliance, undiagnosed diabetes, substance abuse, and coexisting disease. Physical findings of hyperosmolar hyperglycemic state include those associated with profound dehydration and various neurologic symptoms such as coma. The first step of treatment involves careful monitoring of the patient and laboratory values. Vigorous correction of dehydration with the use of normal saline is critical, requiring an average of 9 L in 48 hours. After urine output has been established, potassium replacement should begin. Once fluid replacement has been initiated, insulin should be given as an initial bolus of 0.15 U per kg intravenously, followed by a drip of 0.1 U per kg per hour until the blood glucose level falls to between 250 and 300 mg per dL. Identification and treatment of the underlying and precipitating causes are necessary. It is important to monitor the patient for complications such as vascular occlusions (e.g., mesenteric artery occlusion, myocardial infarction, low-flow syndrome, and disseminated intravascular coagulopathy) and rhabdomyolysis. Finally, physicians should focus on preventing future episodes using patient education and instruction in self-monitoring. Hyperosmolar hyperglycemic state is a relatively common, life-threatening endocrine emergency that is reported in all age groups,1 but it most
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Hyperosmolar Hyperglycemic State

Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.[4] Symptoms include signs of dehydration, weakness, legs cramps, trouble seeing, and an altered level of consciousness.[2] Onset is typically over days to weeks.[3] Complications may include seizures, disseminated intravascular coagulopathy, mesenteric artery occlusion, or rhabdomyolysis.[2] The main risk factor is a history of diabetes mellitus type 2.[4] Occasionally it may occur in those without a prior history of diabetes or those with diabetes mellitus type 1.[3][4] Triggers include infections, stroke, trauma, certain medications, and heart attacks.[4] Diagnosis is based on blood tests finding a blood sugar greater than 30 mmol/L (600 mg/dL), osmolarity greater than 320 mOsm/kg, and a pH above 7.3.[2][3] Initial treatment generally consists of intravenous fluids to manage dehydration, intravenous insulin in those with significant ketones, low molecular weight heparin to decrease the risk of blood clotting, and antibiotics among those in whom there is concerns of infection.[3] The goal is a slow decline in blood sugar levels.[3] Potassium replacement is often required as the metabolic problems are corrected.[3] Efforts to prevent diabetic foot ulcers are also important.[3] It typically takes a few days for the person to return to baseline.[3] While the exact frequency of the condition is unknown, it is relatively common.[2][4] Older people are most commonly affected.[4] The risk of death among those affected is about 15%.[4] It was first described in the 1880s.[4] Signs and symptoms[edit] Symptoms of high blood sugar including increased thirst (polydipsia), increased volume of urination (polyurea), and i
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Managing Hyperosmolar Syndrome

Go to site For Pet Owners Hyperosmolar syndrome is an uncommon complication of untreated feline diabetes mellitus. In animals in which target tissue resistance to insulin plays a role in the disease, insulin levels can be elevated. In these cases, ketosis is suppressed and plasma glucose concentrations can become very high. Diagnosis Physical examination often reveals profound dehydration, and the cat is typically lethargic, extremely depressed, or comatose. The severity of the hyperosmolality correlates directly with the severity of these signs. Hyperosmolar syndrome represents an emergency situation. Affected cats will become progressively weaker, anorexic, lethargic, and drink less. Ultimately, blood glucose levels become so high that osmosis shifts water from brain cells and coma results. Management guidelines Goals of management include correcting fluid deficits and electrolyte balance associated with severe dehydration, reducing blood glucose via insulin therapy, correcting the hyperglycemic, hyperosmolar state, and managing concurrent diseases. Fluid therapy is critical to alleviate this syndrome, especially in the first 4 to 6 hours of management. The goal is to reduce blood glucose at the rate of 50 mg/dL/hr. When the blood glucose approaches 300 mg/dL, the IV fluid selection should be changed to 5% dextrose solution. Intravenous isotonic fluid and insulin therapy usually resolve hyperosmolality, but must be done slowly to minimize the shift of water from the extracellular to the intracellular compartment. Delay insulin therapy (typically 4–6 hours) until fluid therapy has improved the cat’s condition, corrected dehydration and improved urine production, hyperglycemia, hyperosmolality, and electrolyte levels. Evaluation of management When evaluating the eff
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Hyperglycemic

(redirected from hyperglycemic hyperosmolar nonketotic coma (HHNK)) Also found in: Dictionary. hyperglycemic [hi″per-gli-se´mik] 1. characterized by or causing hyperglycemia. 2. an agent that has this effect. hyperglycemic hyperosmolar nonketotic (HHNK) coma a metabolic derangement in which there is an abnormally high serum glucose level without ketoacidosis. It can occur as a complication of borderline and unrecognized diabetes mellitus, in pancreatic disorders that interfere with the production of insulin, as a complication of extensive burns, and in conditions marked by an excess of steroids, as in steroid therapy, or acute stress conditions, such as infection. It also may develop during total parenteral nutrition, hemodialysis, or peritoneal dialysis. Called also hyperosmolar nonketotic coma. Symptoms. The hyperglycemia of HHNK coma is usually extreme, with fasting blood sugar levels ranging from 600 to 3000 mg per 100 ml of blood. In contrast to typical diabetic coma, however, the serum acetone level is normal or only slightly elevated. This occurs because, although there is sufficient insulin available to avoid ketosis, there is not enough to metabolize the glucose and thereby relieve the hyperglycemia. Hyperosmolality, resulting from the extremely high concentration of sugar in the blood, causes a shift of water from the intracellular fluid (the less concentrated solution) into the blood (the higher concentrated solution). This results in cellular dehydration. Another symptom of HHNK coma, polyuria, occurs because the high plasma osmolality prevents the normal osmotic return of water to the blood by the renal tubules, and it is excreted in the urine. This leads to a decreased blood volume, which severely hampers the kidney's excretion of glucose and a vicious
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Diabetic Hyperglycemic Hyperosmolar Syndrome

HHS; Hyperglycemic hyperosmolar coma; Nonketotic hyperglycemic hyperosmolar coma (NKHHC); Hyperosmolar nonketotic coma (HONK); Hyperglycemic hyperosmolar non-ketotic state; Diabetes - hyperosmolar Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. It involves extremely high blood sugar (glucose) level without the presence of ketones. Causes HHS is a condition of: Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis. HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Infection Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain. Risk factors include: Impaired thirst Older age Poor kidney function Poor management of diabetes, not following the treatment plan
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Abstract DKA and HHS represent two extremes in the spectrum of decompensated diabetes mellitus. Their pathogenesis is related to absolute or relative deficiency in insulin levels and elevations in insulin counterregulatory hormones that lead to altered metabolism of carbohydrate, protein, and fat and varying degrees of osmotic diuresis and dehydration, ketosis, and acidosis. In DKA, insulin deficiency and ketoacidosis are the prominent features of the clinical presentation, and insulin therapy is the cornerstone of therapy. In HHS, hyperglycemia, osmotic diuresis, and dehydration are the prominent features, and fluid replacement is the cornerstone of therapy. As many as one-third of patients may have mixed features of both DKA and HHS. Because the three-pronged approach to therapy for either DKA or HHS consists of fluid administration, intravenous insulin infusion, and electrolyte replacement, mixed cases are managed using the same approach. The therapeutic regimen is tailored according to the prominent clinical features present. In adult patients with mixed features, fluids may be administered more rapidly than they would be in younger patients, or in patients with DKA alone, because the risk for fatal cerebral edema in adults is low and the consequences of undertreatment include vascular occlusion and increased mortality. In younger patients with mixed features, rapid correction of metabolic abnormalities and, consequently, of hyperosmolarity by administration of hypotonic fluids and insulin should be avoided to decrease the risk for precipitating cerebral edema. In addition, if ketoacidosis has been a prominent feature in a mixed case, the patient may have type 1 diabetes with no residual pancreatic islet beta cell secretion and may subsequently need ongoing, life-lo
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Diabetic Hyperglycemic Hyperosmolar Syndrome

HHS; Hyperglycemic hyperosmolar coma; Nonketotic hyperglycemic hyperosmolar coma (NKHHC); Hyperosmolar nonketotic coma (HONK); Hyperglycemic hyperosmolar non-ketotic state; Diabetes - hyperosmolar Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. It involves extremely high blood sugar (glucose) level without the presence of ketones. Causes HHS is a condition of: Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis. HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Infection Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain. Risk factors include: Symptoms Symptoms may include any of the following: Symptoms may get worse over days or weeks. Other symptoms
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Diabetic Hyperglycemic Hyperosmolar Syndrome

Diabetic hyperglycemic hyperosmolar syndrome Diabetic hyperglycemic hyperosmolar syndrome Also known as: HHS, Hyperglycemic hyperosmolar coma, Nonketotic hyperglycemic hyperosmolar coma (NKHHC), Hyperosmolar nonketotic coma (HONK), Hyperglycemic hyperosmolar non-ketotic state or Diabetes - hyperosmolar Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes . It involves extremely high blood sugar (glucose) level without the presence of ketones. Extremely high blood sugar (glucose) level Decreased alertness or consciousness (in many cases) Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis . HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's
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What Is Hyperosmolar Hyperglycemic Nonketotic Syndrome?

Having diabetes means that there is too much sugar (glucose) in your blood. When you eat food, your body breaks down much of the food into glucose. Your blood carries the glucose to the cells of your body. An organ in your upper belly, called the pancreas, makes and releases a hormone called insulin when it detects glucose. Your body uses insulin to help move the glucose from the bloodstream into the cells for energy. When your body does not make insulin (type 1 diabetes), or has trouble using insulin (type 2 diabetes), glucose cannot get into your cells. The glucose level in your blood goes up. Too much glucose in your blood (also called hyperglycemia or high blood sugar) can cause many problems. People with type 2 diabetes are at risk for a problem called hyperosmolar hyperglycemic nonketotic syndrome (HHNS). It is very rare in people with type 1 diabetes. HHNS is an emergency caused by very high blood sugar, often over 600 mg/dL. Your kidneys try to get rid of the extra blood sugar by putting more sugar into the urine. This makes you urinate more and you lose too much body fluid, causing dehydration. As you lose fluids, your blood becomes thicker and your blood sugar level gets too high for the kidneys to be able to fix. With the high blood sugar and dehydration there is also an imbalance of minerals, especially sodium and potassium in the blood. The imbalance of fluids, glucose, and minerals in the body can lead to severe problems, such as brain swelling, abnormal heart rhythms, seizures, coma, or organ failure. Without rapid treatment, HHNS can cause death. What can I expect in the hospital? You will need to stay in the hospital in order to bring your blood sugar level under control and treat the cause of the HHNS. Several things may be done while you are in the ho
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Hyperosmolar Hyperglycemic State (hhs)

Hyperosmolar hyperglycemic state is a complication of diabetes mellitus that most often occurs in type 2 diabetes. Symptoms of hyperosmolar hyperglycemic state include extreme dehydration and confusion. Hyperosmolar hyperglycemic state is diagnosed by blood tests that show very high levels of glucose and very concentrated blood. There are two types of diabetes mellitus, type 1 and type 2. In type 1 diabetes, the body produces almost no insulin, a hormone produced by the pancreas that helps sugar (glucose) move from the blood into the cells. In type 2 diabetes, the body produces insulin, but cells fail to respond normally to the insulin. In both types of diabetes. the amount of sugar (glucose) in the blood is elevated. If people with type 1 diabetes receive no insulin, or they need more insulin because of an illness, fat cells begin breaking down to provide energy. Fat cells that break down produce substances called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis). Diabetic ketoacidosis is a dangerous, sometimes life-threatening, disorder. Because people with type 2 diabetes produce some insulin, ketoacidosis does not usually develop even when type 2 diabetes is untreated for a long time. However, with hyperosmolar hyperglycemic state, the blood glucose levels can become extremely high (even exceeding 1,000 mg per deciliter of blood). Such very high blood glucose levels cause the person to pass large amounts of urine, which eventually causes severe dehydration and makes the person's blood abnormally concentrated (hyperosmolar). Thus, the disorder is called hyperosmolar hyperglycemic state. Symptoms The main symptom of hyperosmolar hyperglycemic state is a mental change. The change ranges from mild confusion and disorientatio
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Diabetic Hyperglycemic Hyperosmolar Syndrome

HHS; Hyperglycemic hyperosmolar coma; Nonketotic hyperglycemic hyperosmolar coma (NKHHC); Hyperosmolar nonketotic coma (HONK); Hyperglycemic hyperosmolar non-ketotic state; Diabetes - hyperosmolar Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. It involves extremely high blood sugar (glucose) level without the presence of ketones. Causes HHS is a condition of: Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis. HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Infection Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain. Risk factors include: Impaired thirst Older age Poor kidney function Poor management of diabetes, not following the treatment plan
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Treatment Of Hyperglycaemic Hyperosmolar Non-ketotic Syndrome.

Abstract Hyperglycaemic hyperosmolar non-ketotic syndrome (HHNS) is a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterised by severe hyperglycaemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of ketoacids. HHNS is typically observed in elderly patients with non-insulin-dependent diabetes mellitus, although it may rarely be a complication in younger patients with insulin-dependent diabetes, or those without diabetes following severe burns, parenteral hyperalimentation, peritoneal dialysis, or haemodialysis. Patients receiving certain drugs including diuretics, corticosteroids, beta-blockers, phenytoin, and diazoxide are at increased risk of developing this syndrome. Patients usually present with a prolonged phase of osmotic diuresis leading to severe depletion of both the intracellular and extracellular fluid volumes. Losses of water exceed those of sodium, resulting in hypertonic dehydration. Therefore, correction of the syndrome will ultimately require administration of hypotonic fluids. Patients presenting with HHNS also have significant depletion of potassium and other electrolytes that will need to be replaced. The principal goal at the outset of therapy must be restoration of the intravascular volume to assure adequate perfusion of vital organs. It remains controversial whether 0.9% or 0.45% NaCl should be the initial fluid infused intravenously. We prefer to administer 0.9% NaCl until the vital signs have stabilised and then substitute 0.45% NaCl. 10 to 15 units of regular human insulin should be injected as a bolus, followed by a continuous infusion of approximately 0.1 U/kg/h. Once the blood glucose approaches 13.9 to 16.7 mmol/L (250 to 300) mg/dl, 5% de
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